496803905-5-4-2023-21-AS-DALO-CRHRY9-20230504132559

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803905
Report Date: 05/04/2023
Date Signed: 05/04/2023 01:26:14 PM

Document Has Been Signed on 05/04/2023 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	ARBOL RESIDENCES OF SANTA ROSA		FACILITY NUMBER:	496803905
ADMINISTRATOR:	SORIANO, MARIELE		FACILITY TYPE:	741
ADDRESS:	300 FOUNTAINGROVE PARKWAY		TELEPHONE:	(707) 566-8600
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	152	CENSUS: 103	DATE:	05/04/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Mariele Soriano-Administrator		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Alviso, conducted a Annual Continuation visit, on 5/4/23 at approximately 9:30am, and met with Administrator/Executive Director Mariele Soriano. This is a continuation of the Required 1-Year visit started on 5/1/23, see report LIC809/LIC809D, of this date. LPA reviewed 6 resident files. All resident files were complete. The LPA reviewed 6 staff files. All staff had required training. All direct care staff have first aid certification as required, and most direct caregivers have current CPR certification. Staff files were complete. LPA reviewed resident incident reports to obtain additional information. LPA reviewed staff files as needed regarding the incidents. Administrator Mariele provided records and information to the LPA regarding the resident incidents reviewed, and staff that were on duty during the incident(s). LPA obtained copies from the Administrator as requested. The LPA reviews, and interviews revealed that a resident( R9) had a fall, rang the call bell for assistance, and staff never answered the resident's emergency call bell. Staff(3 of 3) on duty never answered/responded to the call bell, staff (3 of 3) took NO action regarding resident's call for help, and the resident laid on the floor for five plus(5+) hours with a serious injury, a fracture, which posed an immediate health and safety risk to the resident(s) in care. This deficiency will be cited, violation to Health and Safety Code Enumerated Rights 1569.269(a)(6) Residents of residential care facilities for the elderly shall have all of the following rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs, see LIC809D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and/or Health & Safety Code. Failure to correct the deficiency(s) and/or repeat deficiencies within a 12 month period may result in civil penalties being assessed. Exit interview conducted with Mariele Soriano. Appeal rights given to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/04/2023 01:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ARBOL RESIDENCES OF SANTA ROSA	FACILITY NUMBER: 496803905
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.269(a)(6)

Enumerated Rights 1569.269(a)(6) Residents of residential care facilities for the elderly shall have all of the following rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews with (1) of (1) staff//S1, record reviews (3) of (3) staff, review of obtained reports/records regarding the incident, facility failed to have qualified and competent staff to provide care, supervision, and services to a resident(R9) who had a fall and rang the call bell for assistance by staff. Staff(3 of 3) on duty never answered/responded to the call bell, staff (3 of 3) took no action regarding resident call for help, and the resident laid on the floor for five plus(5+) hours with a serious injury, a fracture, which posed an immediate health and safety risk to the resident(s) in care.
	POC Due Date: 05/05/2023
	Plan of Correction
1 2 3 4	Facility to ensure all staff are trained, qualified, and competent to meet all needs of the residents in care; Facility Licensee/Administrator to ensure all staff obtain in-service training in policy and procedures regarding facility’s emergency call bell system, responding to emergency incidents regarding residents, and notifying required parties, review of elder abuse training and reporting as required. Submit proof of training by 5/26/23. Administrator to submit plan of correction by 5/5/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023

LIC809 (FAS) - (06/04)

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